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Pharmacy Prior Authorization

Pharmacy fee for service Prior Authorization (PA)  Contacts

Change Healthcare Pharmacy PA Unit
Toll-free: 877-537-0722
Fax: 877-537-0720

Mississippi Medicaid Prescribers

Registered Users
If you are a Mississippi Medicaid prescriber, submit your prior authorization requests through the Change Healthcare provider portal.

All providers should register at the following link to submit prior authorization requests:

Those Without Web Portal Access
For Mississippi Medicaid prescribers who are unable to submit prior authorizations through the Envision web portal, fax your request to Change Healthcare Pharmacy PA unit.

Drug Prior Authorization Instructions

Prior Authorization Packets Updated
Brand Name Multi-Source 5/5/2017
Early Refill 5/5/2017
Enteral Nutrition 1/26/2018
EPSDT – Beneficiaries Under 21 3/1/2018
Heterozygous Familial Hypercholesterolemia (HeFH) – REPATHA™ (EVOLOCUMAB) and PRALUENT® (ALIROCUMAB) 5/5/2017
Hepatitis C Therapy 7/1/2018
Homozygous Familial Hypercholesterolemia (HoFH) – REPATHA™ (EVOLOCUMAB) 5/5/2017
Max Unit Override 5/5/2017
Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) 5/15/2017
PDL Exception Request 5/5/2017
RSV-SYNAGIS® 10/1/2017


Pharmacy Reconsideration Request Form


Pharmacy Prior Authorization – Other Information and Forms